| NPI | 1588604060 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRENDA DE GRAY Credentialing Mngr 800-370-3651 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner |
| Additional Taxonomies | 103TC0700X Psychologist Clinical |
| 1041C0700X Social Worker Clinical | |
| 2084P0800X Psychiatry & Neurology Psychiatry | |
| Enumeration Date | 2006-06-07 |
| Last Update Date | 2009-05-26 |